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UM Criteria
  

UM Criteria

Astiva Health - Prior Authorization and Clinical Policy Guidelines



Clinical Guidelines – Medicare (NCD/LCD) & Astiva Utilization Management Policies

Astiva Health is committed to providing quality care and services to the members in our network. Here you will find information for assessing coverage options; including Medicare National Coverage Determinations (NCD) and Medicare Local Coverage Determinations (LCD) which are decisions by Medicare and their administrative contractors that provide coverage information and determine whether services are reasonable and necessary. These guidelines apply across the United States and in California where Medicare provides health coverage. Medicare NCDs/LCDS are made through evidence-based processes, with opportunities for public participation.

Astiva Health provides its members with certain services where there is an absence of any applicable Medicare statutes, regulations, NCDs or LCDs setting forth coverage criteria. Supplemental benefits are developed utilizing internal criteria and widely accepted Apollo Managed Care Clinical Guidelines (licensed to Astiva Health) to develop its prior authorization rationale to ensure medically reasonable services that aim to cost-effectively support the functional needs and enhance the clinical outcomes of its enrollees.

 
Medicare
National Coverage Determinations
A National Coverage Determination (NCD) is a decision about particular treatments that Medicare will or will not cover for particular conditions. Medicare contractors are required to follow NCDs.
 
Medicare
Local Coverage Determinations
LCDs are decisions made by a Medicare Administrative Contractor (MAC) whether to cover a particular item or service in a MAC's jurisdiction (region) in accordance with section 1862(a)(1)(A) of the Social Security Act.
 
Astiva Health
Health Policy Guidelines
Astiva Health Policies are created and approved by an established Utilization Management Committee to ensure services are medically reasonable, cost-effective, prevent harm, reduce barriers to access, support functional needs, and enhance social and clinical outcomes of enrollees.

Astiva Health - Prior Authorization and Clinical Policy Guidelines



Clinical Guidelines – Medicare (NCD/LCD) & Astiva Utilization Management Policies

Astiva Health is committed to providing quality care and services to the members in our network. Here you will find information for assessing coverage options; including Medicare National Coverage Determinations (NCD) and Medicare Local Coverage Determinations (LCD) which are decisions by Medicare and their administrative contractors that provide coverage information and determine whether services are reasonable and necessary. These guidelines apply across the United States and in California where Medicare provides health coverage. Medicare NCDs/LCDS are made through evidence-based processes, with opportunities for public participation.

Astiva Health provides its members with certain services where there is an absence of any applicable Medicare statutes, regulations, NCDs or LCDs setting forth coverage criteria. Supplemental benefits are developed utilizing internal criteria and widely accepted Apollo Managed Care Clinical Guidelines (licensed to Astiva Health) to develop its prior authorization rationale to ensure medically reasonable services that aim to cost-effectively support the functional needs and enhance the clinical outcomes of its enrollees.

Medicare
National Coverage Determinations
A National Coverage Determination (NCD) is a decision about particular treatments that Medicare will or will not cover for particular conditions. Medicare contractors are required to follow NCDs.
Medicare
Local Coverage Determinations
LCDs are decisions made by a Medicare Administrative Contractor (MAC) whether to cover a particular item or service in a MAC's jurisdiction (region) in accordance with section 1862(a)(1)(A) of the Social Security Act.
Astiva Health
Health Policy Guidelines
Astiva Health Policies are created and approved by an established Utilization Management Committee to ensure services are medically reasonable, cost-effective, prevent harm, reduce barriers to access, support functional needs, and enhance social and clinical outcomes of enrollees.